Citation Nr: 18148960 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 16-29 801 DATE: November 8, 2018 ORDER Service connection for headaches is granted. Service connection for an acquired psychiatric disorder, to include major depressive disorder, is granted. A rating in excess of 20 percent for degenerative disc disease of the cervical spine is denied. An initial rating in excess of 10 percent for cervical radiculopathy of the left upper extremity is denied. A rating in excess of 20 percent for lumbar radiculopathy of the left lower extremity is denied. A compensable rating for bilateral hearing loss is denied. REMANDED Entitlement to service connection for numbness of the right hand is remanded. Entitlement to service connection for numbness of the right toes is remanded. Entitlement to a rating in excess of 10 percent for a left knee disability is remanded. Entitlement to a rating in excess of 10 percent for a right knee disability is remanded. Entitlement to a rating in excess of 10 percent for a back disability is remanded. Entitlement to an effective date prior to June 24, 2014, for the grant of service connection for cervical radiculopathy of the left upper extremity is remanded. FINDINGS OF FACT 1. The competent and probative evidence is at least in equipoise as to whether headaches had their onset during or are otherwise related to the Veteran’s period of service. 2. The competent and probative evidence is at least in equipoise as to whether an acquired psychiatric disorder, to include major depressive disorder, had its onset during or is otherwise related to the Veteran’s period of service. 3. The weight of the competent and probative evidence is against finding forward flexion of the cervical spine to 15 degrees or less or ankylosis of the entire cervical spine. 4. The weight of the competent and probative evidence is against finding moderate incomplete paralysis of the left upper extremity. 5. The weight of the competent and probative evidence is against finding moderately severe incomplete paralysis of the left lower extremity. 6. The competent and probative evidence shows hearing loss of no worse than Level I in the right ear and Level I in the left ear. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for headaches have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to a rating in excess of 20 percent for degenerative disc disease of the cervical spine have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, Diagnostic Codes (DCs) 5242-5237. 4. The criteria for entitlement to an initial rating in excess of 10 percent for cervical radiculopathy of the left upper extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, DC 8515. 5. The criteria for entitlement to a rating in excess of 20 percent for lumbar radiculopathy of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.123, 4.124, 4.124a, DC 8520. 6. The criteria for entitlement to a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.85-4.86, DC 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1970 to May 1991. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a February 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). Service Connection 1. Entitlement to service connection for headaches. After review of the record, the Board finds that the criteria for service connection for headaches have been met. The record contains a competent diagnosis of migraines. 12/17/2014, C&P Exam. Accordingly, the Board finds competent evidence of a current disability. Service treatment records demonstrate several complaints of recurring headaches/migraines during service. 11/05/2014, STR-Medical. In January 2016, a private physician opined that it is at least as likely as not that the Veteran’s headache disorder had its onset during or is otherwise related to his period of service, noting in-service complaints of and treatment for headaches/migraines, and the Veteran’s statements regarding post-service recurrence of headaches. 03/02/2017, Correspondence. Additionally, a January 2016 VA examination primary care note reflect that the Veteran report recent headaches and that they have been occurring since the military. In light of the foregoing, the Board finds that the competent and probative evidence is at least in equipoise as to whether the Veteran’s headaches had their onset during or are otherwise related to his period of service. In sum, as all three service connection elements have been established by competent, credible, and probative evidence, the Board finds that service connection is warranted. 2. Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder. After review of the record, the Board finds that the criteria for service connection for an acquired psychiatric disorder have been met. The record contains a competent diagnosis of major depressive disorder with anxious distress. 12/22/2014, C&P Exam. Accordingly, the Board finds competent evidence of a current disability. Service treatment records demonstrate treatment for recurring insomnia during service, with an in-service assessment of insomnia secondary to situational depression. 11/05/2014, STR-Medical. In May 2016, a private psychologist opined that it is at least as likely as not that the Veteran’s psychiatric disorder had its onset during or is otherwise related to his period of service. In support, the psychologist noted in-service complaints of insomnia, an in-service assessment of situational depression, a mental status examination and interview of the Veteran, and lay statements by the Veteran’s brother and sister-in-law describing a change in his personality upon returning home from service. 03/02/2017, Correspondence. The Board acknowledges a December 2014 VA examiner’s opinion that there is no clear nexus between major depressive disorder and service, noting that the Veteran denied psychological concerns at discharge. The Board assigns the VA examiner’s opinion no probative weight, as the wrong standard was used. Additionally, the Board notes that the VA examiner was unable to consider lay statements from the Veteran’s brother and sister-in-law. Accordingly, the Board finds that the competent and probative evidence is at least in equipoise as to whether an acquired psychiatric disorder had its onset during or is otherwise related to his period of service. In sum, as all three service connection elements have been established by competent, credible, and probative evidence, the Board finds that service connection is warranted. Increased Rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran’s disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Id. Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). Disability ratings are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Rating Schedule. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3; see Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the disorder. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath, 1 Vet. App. at 593. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one disorder is not duplicative of the symptomatology of the other disorder. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). 3. Entitlement to a rating in excess of 20 percent for degenerative disc disease of the cervical spine. The Veteran contends that he is entitled to a rating in excess of 20 percent for degenerative disc disease of the cervical spine, evaluated under Diagnostic Codes 5242-5237. The diagnostic codes for the spine are as follows: 5235 Vertebral fracture or dislocation; 5236 Sacroiliac injury and weakness; 5237 Lumbosacral or cervical strain; 5238 Spinal stenosis; 5239 Spondylolisthesis of the lumbar spine or segmental instability; 5240 Ankylosing spondylitis; 5241 Spinal fusion; 5242 Degenerative arthritis of the spine (see also Diagnostic Code 5003); and 5243 Intervertebral Disc Syndrome (IVDS). Diagnostic Codes 5235 through 5243 are rated using the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). The General Rating Formula provides for the following disability ratings for diseases or injuries of the spine, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. It applies to Diagnostic Codes 5235 to 5243 unless the disability rated under Diagnostic Code 5243 is evaluated under the Formula for Rating IVDS Based on Incapacitating Episodes. 38 C.F.R. § 4.71a, General Rating Formula. For purposes of this issue, the Board notes that under the General Rating Formula for diseases and injuries of the spine, ratings are assigned, in pertinent part, as follows: a 20 percent rating is warranted for forward flexion of the cervical spine to 30 degrees or less; combined range of motion of the cervical spine to 170 degrees or less; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent disability rating is warranted for forward flexion of the cervical spine to 15 degrees or less, or favorable ankylosis of the entire cervical spine. A 40 percent disability rating is warranted for unfavorable ankylosis of the entire cervical spine. And a 100 percent disability rating is warranted for unfavorable ankylosis of the entire (thoracolumbar and cervical) spine. See 38 C.F.R. § 4.71a, General Rating Formula. For disabilities evaluated based on limitation of motion, VA is required to apply the provisions of Sections 4.40 and 4.45 pertaining to functional impairment. 38 C.F.R. §§ 4.40, 4.45. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain during flare-ups and after repetitive use over time. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011); DeLuca v. Brown, 8 Vet. App. 202, 208 (1995); 38 C.F.R. § 4.59. The Board notes that 38 C.F.R. § 4.59, entitled “Painful motion,” states, in pertinent part, “The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint.” In Burton v. Shinseki, the Court stated that the scope of § 4.59 is not limited to arthritis claims. 25 Vet. App. 1, 5 (2011). After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that a rating in excess of 20 percent for degenerative disc disease of the cervical spine is not warranted. A December 2014 VA examination indicates forward flexion to 35 degrees, extension to 25 degrees, right and left lateral flexion to 30 degrees, right lateral rotation to 45 degrees, and left lateral rotation to 50 degrees, with pain noted on the examination but not resulting in functional loss, and no additional limitation after three repetitions. The Veteran did not report flare-ups or functional loss due to the neck disability. Pain, fatigue, instability, and weakness do not significantly limit functional ability with repeated use over time. The examiner found no guarding or muscle spasm; normal muscle strength; no muscle atrophy; normal deep tendon reflexes; normal sensation to light touch; no ankylosis; no IVDS; and no assistive devices used. 1222/2014, C&P Exam. The Board finds the December 2014 VA examination to be competent, credible, and highly probative, as it is supported by an in-person examination, testing, medical expertise, and consideration of the lay evidence. Accordingly, the Board finds that a rating in excess of 20 percent is not warranted for degenerative disc disease of the cervical spine because the weight of the competent and probative evidence is against finding forward flexion of the cervical spine to 15 degrees or less or ankylosis of the cervical spine. See 38 C.F.R. § 4.71a. The Board has considered the 38 C.F.R. §§ 4.40, 4.45, and 4.59, and Mitchell and DeLuca criteria, but finds that the competent and probative evidence weighs against finding weakened movement, excess fatigability, incoordination, and/or pain during flare-ups or after repeated use over time resulting in forward flexion of the cervical spine to 15 degrees or less or ankylosis. In other words, the Board finds that the Veteran’s neck disability does not more closely approximate the criteria for a 30 percent evaluation. See 38 C.F.R. § 4.71a. All possibly applicable diagnostic codes have been considered in compliance with Schafrath, 1 Vet. App. at 593, but the Veteran could not receive a higher and/or additional evaluation for his neck disability based on the evidence. See 38 C.F.R. § 4.71a. The Board notes that the benefit of the doubt has been applied, where applicable. 4. Entitlement to an initial rating in excess of 10 percent for cervical radiculopathy of the left upper extremity. The Veteran contends that he is entitled to an initial rating in excess of 10 percent for cervical radiculopathy of the left upper extremity, evaluated under Diagnostic Code 8515. Diseases affecting the nerves are rated based on degree of paralysis, neuritis, or neuralgia under 38 C.F.R. §§ 4.123, 4.124, and 4.124a. For paralysis of the median nerve, mild incomplete paralysis warrants a 10 percent rating; moderate incomplete paralysis warrants a 20 percent rating for the minor hand and a 30 percent rating for the major hand; and severe incomplete paralysis warrants a 40 percent rating for the minor hand and a 50 percent rating for the major hand. Complete paralysis warrants a 70 percent rating for the major hand and a 60 percent rating for the minor hand, and is evidenced by the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscle of the thenar eminence, the thumb in the plane of the hand (ape hand), pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm, flexion of wrist weakened; and pain with trophic disturbances. 38 C.F.R. § 4.124a, DC 8515. The terms “major” and “minor” are used in the rating criteria to refer to the dominant or non-dominant upper extremity. See 38 C.F.R. § 4.69. The evidence demonstrates that the Veteran’s right arm is his dominant upper extremity. 12/22/2014, C&P Exam. The term “incomplete paralysis” indicates a degree of impaired function substantially less than the type of picture for “complete paralysis” given for each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating for incomplete paralysis should be for the mild, or, at most, the moderate degree. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves, Note. Moderate incomplete paralysis will likely be described by the veteran and medically graded as significantly disabling and may be demonstrated by combinations of significant sensory changes and reflex or motor changes of a lower degree, or motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes (with or without sensory impairment) graded as medically moderate. In Miller v. Shulkin, the Court held that “[a]lthough the note preceding § 4.124a directs the claims adjudicator to award no more than a 20% disability rating for incomplete paralysis of a peripheral nerve where the condition is productive of wholly sensory manifestations, it does not logically follow that any claimant who also exhibits non-sensory manifestations must necessarily be rated at a higher level.” 28 Vet. App. 376, 380 (2017). Neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe incomplete paralysis. The maximum rating which may be assigned for neuritis not characterized by such organic changes will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. Tic douloureux may be rated up to complete paralysis of the affected nerve. 38 C.F.R. § 4.124. After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that an initial rating in excess of 10 percent for radiculopathy of the left upper extremity is not warranted. A December 2014 VA examination indicates no constant pain, mild intermittent pain, mild paresthesias and/or dysesthesias, and no numbness of the left upper extremity. Based on these findings, the examiner concluded that the Veteran has mild incomplete paralysis of the median nerve on the left. 12/22/2014, C&P Exam. The Board finds the December 2014 VA examination to be competent, credible, and highly probative, as it is supported by an in-person examination, testing, proper consideration of lay evidence, and medical expertise. Accordingly, the Board finds that the weight of the competent and probative evidence is against finding moderate incomplete paralysis of the left upper extremity. The Board finds that mild pain and mild paresthesias and/or dysesthesias and are considered by the 10 percent rating. In finding that a higher rating is not warranted, the Board notes that the weight of the competent and probative evidence is against finding that the symptoms are significantly disabling, as there is no evidence of muscle atrophy, significant sensory changes, weakness, or diminished or hyperactive reflexes graded as medically moderate. The Board notes that a higher rating is not available under Diagnostic Code 8715 for neuralgia of the median nerve, as the weight of the competent and probative evidence is against finding moderate intermittent pain of the left arm; the December 2014 VA examination indicated at most mild intermittent pain. See 38 C.F.R. § 4.124. Nor can a higher rating be assigned under Diagnostic Code 8615, as the record does not demonstrate neuritis of the median nerve. See 38 C.F.R. § 4.123. All possibly applicable diagnostic codes have been considered in compliance with Schafrath, 1 Vet. App. at 593, but the Veteran could not receive higher and/or additional evaluations for cervical radiculopathy of the left upper extremity based on the evidence. See 38 C.F.R. § 4.124a. The Board notes that the benefit of the doubt has been applied, where applicable. 5. Entitlement to a rating in excess of 20 percent for lumbar radiculopathy of the left lower extremity. For paralysis of the sciatic nerve, a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating is warranted for moderate incomplete paralysis; a 40 percent rating is warranted for moderately severe incomplete paralysis; and a 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy. An 80 percent rating is warranted for complete paralysis, evidenced by the foot dangles and drops, no active movement possible of muscles below the knee, and flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, DC 8520. After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that a rating in excess of 20 percent for lumbar radiculopathy of the left lower extremity is not warranted. A December 2014 VA examination indicates no radicular pain or any other signs or symptoms due to radiculopathy, to include constant pain, intermittent pain, paresthesias and/or dysesthesias, or numbness of the left lower extremity. The examiner found normal muscle strength, no muscle atrophy, normal deep tendon reflexes, and normal sensation to light touch. 12/22/2014, C&P Exam. The Board finds the December 2014 VA examination to be competent, credible, and highly probative, as it is supported by an in-person examination, testing, proper consideration of lay evidence, and medical expertise. Accordingly, the Board finds that the weight of the competent and probative evidence is against finding moderately severe incomplete paralysis of the left lower extremity. As previously noted, when the involvement is wholly sensory, the rating for incomplete paralysis should be for the mild, or, at most, the moderate degree. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves, Note. In finding that a higher rating is not warranted, the Board notes that the weight of the competent and probative evidence is against finding muscle weakness or atrophy. Accordingly, the Board finds that the Veteran is not entitled to a rating in excess of 20 percent for radiculopathy of the left lower extremity based on paralysis of the sciatic nerve. The Board notes that a higher rating is not available under Diagnostic Code 8720 for neuralgia of the sciatic nerve, as the maximum rating available is equal to moderate incomplete paralysis, or 20 percent. See 38 C.F.R. § 4.124. Nor can a higher rating be assigned under Diagnostic Code 8620, as the record does not demonstrate neuritis of the sciatic nerve. See 38 C.F.R. § 4.123. All possibly applicable diagnostic codes have been considered in compliance with Schafrath, 1 Vet. App. at 593, but the Veteran could not receive higher and/or additional evaluations for radiculopathy of the left lower extremity based on the evidence. See 38 C.F.R. § 4.124a. The Board notes that the benefit of the doubt has been applied, where applicable. 6. Entitlement to a compensable rating for bilateral hearing loss. The Veteran contends that he is entitled to a compensable rating for bilateral hearing loss, evaluated under Diagnostic Code 6100. Disability ratings for hearing loss are assigned based on the results of controlled speech discrimination tests combined with the results of pure tone audiometry tests. See 38 C.F.R. §§ 4.85-4.86. An examination for VA rating purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test, specifically, the Maryland CNC test, and a puretone audiometry test. 38 C.F.R. § 4.85(a). Further, disability ratings for hearing impairment are assigned through a structured formula, i.e., a mechanical application of the rating schedule to numeric designations that are assigned after audiometric evaluations have been rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). First, a Roman numeral designation of I through XI is assigned for the level of hearing impairment in each ear. Table VI is used to determine a Roman numeral designation based on a combination of the speech discrimination percentage and the average pure tone threshold, or the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four. After a Roman numeral designation has been assigned for each ear, Table VII is used to determine the compensation rate by combining such designations for hearing impairment in both ears. 38 C.F.R. § 4.85. When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). When the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher. 38 C.F.R. § 4.86(b). The schedular rating criteria specifically provide for ratings based on all levels of hearing loss in various contexts, as measured by both audiometric testing and speech recognition testing. The ability of the Veteran to hear sounds and voices is measured and rated by an audiometric test, as this test measures different frequencies and captures high frequency hearing loss from sources including voices, music, sirens, and certain high pitched sounds. The ability of the Veteran to understand people and having to ask others to repeat themselves on a regular basis is rated by a speech recognition test, as this test measures conversation comprehension, words, and missed conversations. The schedular rating criteria specifically provide for ratings based on all levels of hearing loss, including exceptional hearing patterns, and as measured by both audiometric testing and speech recognition testing. See Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017) (holding that “the rating criteria for hearing loss contemplate the functional effects of difficulty hearing and understanding speech”). After reviewing the relevant medical and lay evidence and applying the above laws and regulations, the Board finds that Veteran is not entitled to a rating in excess of 10 percent for bilateral hearing loss. The Board first notes that the Veteran does not have an exceptional pattern of hearing impairment, as defined by 38 C.F.R. § 4.86. All applicable tests include valid puretone and speech discrimination scores. As such, Table VI applies. See 38 C.F.R. §§ 4.85-4.86. In December 2014, the Veteran was given an audiological examination by a VA audiologist, and recorded puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 15 10 30 65 30 LEFT 10 10 40 60 30 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and 100 percent in the left ear. 12/23/2014, C&P Exam. The results of the December 2014 audiological examination combine for I in the right ear and I in the left ear in Table VI. Roman numerals I and I combine for a noncompensable rating in Table VII. See 38 C.F.R. § 4.85. The Veteran has reported that hearing loss results in difficulty understanding low sounds, birds, music, and speech when a person is far away. As previously noted, VA’s audiometric tests are specifically designed to measure the functional effects of decreased hearing and difficulty understanding speech in an everyday work and other environments; thus, difficulty understanding certain sounds and conversation as a distance is contemplated by the rating criteria. See Doucette, 28 Vet. App. at 369. Applying the audiological test results most favorable to the Veteran to the regulatory criteria, the Board concludes that the preponderance of the evidence is against entitlement to a compensable rating for bilateral hearing loss. See 38 C.F.R. §§ 4.85-4.86. For the entire rating period on appeal, all possible applicable diagnostic codes have been considered, but the Veteran could not receive a higher disability rating for bilateral hearing loss. See 38 C.F.R. §§ 4.85-4.86. Indeed, when a condition is listed in the schedule, rating by analogy is not appropriate. Copeland v. McDonald, 27 Vet. App. 333, 336-37 (2015). REASONS FOR REMAND 1. Entitlement to service connection for numbness of the right hand is remanded. 2. Entitlement to service connection for numbness of the right toes is remanded. VA examinations in December 2014 indicate that the Veteran is not experiencing symptoms of lumbar and/or cervical radiculopathy affecting the right upper and lower extremities; however, the examinations do not provide an alternative etiology for numbness of the right hand and toes. Accordingly, the Agency of Original Jurisdiction (AOJ) should schedule the Veteran for an examination to determine the etiology of numbness of the right hand and toes. 3. Entitlement to a rating in excess of 10 percent for a left knee disability is remanded. 4. Entitlement to a rating in excess of 10 percent for a right knee disability is remanded. 5. Entitlement to a rating in excess of 10 percent for a back disability is remanded. December 2014 VA examinations for the back and knees are inadequate because the Board is unable to determine whether the examiner’s inability to offer an opinion as to whether pain, fatigue, weakness, and/or instability significantly limit range of motion of the back and bilateral knees after repetitive use over time without resolving to mere speculation is due to a deficiency in the examiner, as opposed to in the knowledge of the medical community more generally. See Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). As such, the Board remands these issues for another examination(s). 6. Entitlement to an effective date prior to June 24, 2014, for the grant of service connection for cervical radiculopathy of the left upper extremity is remanded. In an April 2015 notice of disagreement (NOD), the Veteran appealed the effective date of June 24, 2014, assigned for the grant of service connection for cervical radiculopathy of the left upper extremity. The AOJ has not issued a statement of the case (SOC) regarding the earlier effective date claim. As such, the Board has no discretion, and the issue must be remanded for such a purpose. Manlincon v. West, 12 Vet. App. 238, 240 (1999); 38 C.F.R. § 19.9(c). The matters are REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from April 2016 to the present. 2. After completing directive #1, schedule the Veteran for an examination with an appropriate clinician to determine the nature and etiology of numbness of the right hand. The clinician should review the virtual file, including a copy of this Remand. The clinician is to address the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that numbness of the right hand manifested during or is otherwise related to the Veteran’s period of active service. (b.) Whether it is at least as likely as not (50 percent or greater probability) that numbness of the right hand is due to a service-connected disability, to include cervical degenerative disc disease and/or associated radiculopathy. (c.) Whether it is at least as likely as not (50 percent or greater probability) that numbness of the right hand has been aggravated (i.e., worsened beyond the normal progression of that disease) by a service-connected disability, to include cervical degenerative disc disease and/or associated radiculopathy. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. After completing directive #1, schedule the Veteran for an examination with an appropriate clinician to determine the nature and etiology of numbness of the right toes. The clinician should review the virtual file, including a copy of this Remand. The clinician is to address the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that numbness of the right toes manifested during or is otherwise related to the Veteran’s period of active service. (b.) Whether it is at least as likely as not (50 percent or greater probability) that numbness of the right toes is due to a service-connected disability, to include lumbar degenerative disc disease and/or associated radiculopathy. (c.) Whether it is at least as likely as not (50 percent or greater probability) that numbness of the right toes has been aggravated (i.e., worsened beyond the normal progression of that disease) by a service-connected disability, to include lumbar degenerative disc disease and/or associated radiculopathy. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. After completing directive #1, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected lumbar spine disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s back disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups (if reported), and the degree of functional loss during flare-ups (if reported) and after repetitive use over time in terms of degrees of motion loss. To the extent possible, the examiner should identify any symptoms and functional impairments due to the back disability alone and discuss the effect of the Veteran’s back disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 5. After completing directive #1, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected bilateral knee disabilities. The examiner should provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran’s bilateral knee disabilities under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups (if reported), and the degree of functional loss during flare-ups (if reported) and after repetitive use over time in terms of degrees of motion loss. To the extent possible, the examiner should identify any symptoms and functional impairments due to the bilateral knee disabilities alone and discuss the effect of the Veteran’s bilateral knee disabilities on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training).   6. Send the Veteran and his representative a statement of the case that addresses the issue of entitlement to an effective date prior to June 24, 2014, for the grant of service connection for cervical radiculopathy of the left upper extremity. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issue should be returned to the Board for further appellate consideration. Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J.A. Gelber, Associate Counsel